Scalpel had an interesting post today about treating a patient who was psychotic by any reasonable definition: hallucinating and with strong signs of potential violence, but at least partially cooperative with treatment. Scalpel and his nursing staff had to wrestle with the dilemma of whether they could administer anti-psychotic medications without his consent.

I always find this sort of thing interesting. In most cases, as long as you can document your clinical judgment that you believe that the patient was either unable to make an informed refusal of care, or presented an imminent danger to self or others, you're pretty safe doing whatever you need to in order to care for the patient. For ER docs, that often involves four-point leather restraints, sedation, occasionally medical procedures (i.e. gastric lavage, also known as pumping the stomach, or life-support such as endotracheal intubation), and often involuntarily detaining the person pending psychiatric hospitalization.

In our state, there is an interesting twist, though. To my knowledge, Washington is unique in that physicians do not have the authority to place patients on any sort of "72 hour hold." Not even psychiatrists. Instead, state law delegates this authority to trained officers of the court called "County Designated Mental Health Professionals," or CDMHPs.

It's an interesting system, and in my mind works well, though a bit kludge-y. I can basically do whatever I want to someone in my ER, provided that it is grounded in good medical reasoning. But if I think someone is or might be a threat, then I call in the CDMHP. They take over from there, and evaluate the patient and determine whether they meet the statutory definition of either an "imminent threat to self or others" or "gravely disabled." If so, they are detained, and the CDMHP finds a bed for them somewhere. If not, they are released, and both the CDMHP and I have immunity from liability should the patient go home and harm self or others.

But I get caught in the middle, in some cases, with a bit of a catch-22. I do not have the legal authority to detain them, so my clinical opinion is meaningless regarding whether the patient goes to the rubber room in the end. I must, however, do a medical evaluation and determine that there is no medical emergency or other non-psychiatric cause of the patient's behavior before I can call in the CDMHP. This usually involves some lab tests (a tox screen, for example) and maybe a CT scan of the brain, and the patient must be sober before the CDMHP can evaluate them. And they are busy. So there is always a lag time, sometimes significant, before the CDMHP evaluates the patient, and I need to control the patient during that time.

The best way to control an agitated, uncooperative, hallucinating patient is to administer an anti-psychotic med like Haldol, as Scalpel did. It's very effective, and much more pleasant than having them in leather four-points screaming and thrashing for hours on end. (Not to mention that physical restraints in such situations can be quite dangerous to the patient.)

Then, hours later, the CDMHP shows up and finds the patient polite and cooperative and not at all dangerous or disabled. The voices are gone and the patient no longer has the urge to kill. The CDMHPs ruefully shake their heads, agree that it sounded like he was pretty nutty when he first arrived, but, "Sorry, he just doesn't meet the criteria to be detained. Send him home."

So I have the choice of leaving the psych patients untreated for hours, possibly endangering patients and staff, or treating them early and precluding any more definitive treatment... argh. We do our best to work around it with short-acting sedatives and locked doors with heavy security presence. But when you have an irritating, obnoxious bipolar in the manic phase screaming sexual obscenities for hours on end, and your hands are tied, it's extremely frustrating.

It is, however, the happiest moment of my day when the CDMHP shows up, stands in the doorway for thirty seconds, then seeks me out and says, "Would you PLEASE get that guy some Haldol?"

21 December 2007

I saw this sign and thought it was amusing so I snapped a picture of it. Any guesses as to what happened about thirty seconds afterwards?

I think I actually cartwheeled. I didn't slide much, but it took me a while to find my left ski, which was about 50 feet downhill, standing straight up in the snow. And yes, there was an audience on the chairlift to bear witness of my humiliation.

Skiing karma.

Oh well. At least it was my only fall of the day. There's some consolation.

20 December 2007

Commenter JimII writes:So, here's my question, do all doctors hate their patients? Or is it just ER doctors, or is it ER doctors who blog?It is funny because it is clear that Movin' Meat is an Oasis in the blogosphere desert of hate that is ER blogging, but it has nonetheless opened my eyes to the people being glorified every night on the TeeVee and lauded by popular culture.The hatred of the poor is particularly obnoxious. The constant snark about people with publicly funded insurance really bothers me.

I think JimII has a pretty valid point. I try real real hard not to slide down the slippery slope of contempt and hate towards my patients. But the truth cannot be denied that the ER is a particularly effective bottom filter of society. And that ER patients frequently are nutty, or self-destructive, and drug-addicted or alcoholic, or just malignant, manipulative abusers of the system. Medicaid patients, in particular, utilize the ER too frequently and for inappropriate purposes.

So I get it. ER patients are maddening (at least a significant subset of them), and one's blog is a great place to vent about them, as I did today over at MedPage. After all, isn't ranting what blogs are all about? I can, however, see how some people might interpret the ranting as excessive, and there have been times where, reading other medbloggers' posts, I have felt distinctly uncomfortable at the demonization of their patients. I'm not sure where the line is that separates a mordant sense of humor and a bleak cynicism from outright contempt. I often worry that I am crossing that line. There are some blogs that I just don't visit anymore because they were far enough over the line that I couldn't enjoy reading them. There are some blogs that seem to skate back and forth across the line on a daily basis.

I do remember one time in medical school, when I was very frustrated trying to care for an ornery patient at the VA, when a senior resident took me aside and told me that, "sometimes, it's OK to hate your patients." It was something of a seminal moment for me. Prior to that I had the wide-eyed naive idea that I would enjoy and like all of them, I think. Getting permission to dislike my patients was a big step in learning that clinical detachment that is essential to this job.

Having been given that permission, though, it can be a challenge to keep it in check.

19 December 2007

I've blogged on this point before, and I will again. I couldn't agree more. What other vocational school leaves its graduates completely ignorant of the economic underpinnings of the industry they are training to enter?

Sing it, brother!

-----Updated-----

Arrgh. Even the usually sensible Graham doesn't get it. He seems to endorse the notion that:

The point of med school ... is to give you a foundation of knowledge to learn how to practice medicine, get exposed to all the medical specialties, and prepare you for internship. It’s residency that should be teaching doctors about how to be an attending.

Med school is about more than preparing you for internship. There's 30+ years of practice to follow, and you need to be prepared for that, also. It's not too hard to teach students some universal concepts about the business of medicine. A few lectures on contract law, some talks on professional negligence, maybe a bit on professional liability insurance, the difference between ICD-9 and CPT coding, a primer on various forms of reimbursement and how it is determined, the concept of Accounts Receivable, and some info on the RVRBS and how it relates to reimbursement. You hardly need an MBA. It could be done in a few weeks with half an hour three times a week, and could be crafted such that it would be applicable to students going into any specialty.

Don't kid yourself that residencies could or should do this. Residents are scattered all over the hospital working, and the lecture time in residency is a tiny fraction of that available in med school, and proportionately more precious. It would be better than nothing, and IMO, more advanced, specialty-specific talks on your future career should be a component of residency education. But as it is both residencies and med schools are abject failures in preparing future doctors for the realities of the medical economy. The result is that young doctors get exploited, and that doctors in general are crappy businessmen, and crappy advocates for health care reform. And that's an ongoing tragedy for the medical profession.

17 December 2007

IF: you are a patient who has a complex ongoing medical problem, for example: cancer for which you are being treated; a major surgery for which you have had a series of awful complications; a recent transplanted organ; or some extremely rare genetic condition,

AND IF: your treatment is being coordinated by doctors at The Big Hospital Downtown

THEN: please, please, please for the love of God, do not come to my ER.

It's not that we don't want to see you. We would love to, but the fact is that we will not be able to care for you properly at our hospital, so don't come here. It's that simple. We are not bad doctors here, nor are we unused to to complex patients. Believe me, we have lots of cancer patients here, and our surgeons have lots of complications of their own, etc, etc, etc. But your doctors are not here. And your records are not here. I may not be able to get your records, and even if I do, it will take me hours and I will probably not get everything I wanted. Your care will be delayed and possibly harmed. And I may have trouble reaching your doctors because I don't know the secret access number to the paging services at The Big Hospital. And even if I am able to get your doctors on the phone, they don't know me, which means they won't trust me. They may assume that I am an idiot (a common prejudice towards community docs by academics), in which case they won't listen to a word I say. They may think that I am trying to "dump" a problem patient back on them, in which case they will resist any recommendation that I transfer you back to their hospital. Worse, they may actively try to "dump" a difficult case on us by refusing to accept you back. (It's funny how doctors' sense of "ownership" of a patient diminishes when the patient shows up at a distant hospital.) Or I may just get a resident who doesn't know you and doesn't give a crap; it's hard to get an academic attending on the phone at 2AM. And what's more, if the doctors at The Big Hospital Downtown refuse to aceept you in transfer, it's also possible that my specialists here will also refuse to take you on as a patient. They aren't supposed to, but it is predictable that they will tell me that you should just "go back Downtown." And then you, and I, are stuck in the middle with nowhere to go.

So don't come here. If you think you are getting worse, get in the car and drive yourself back to the Mecca where you were treated. By the way, that means don't call 911 for convenience of transport. They will ignore your protestations that you want to go Downtown and take you to the closest hospital, because they don't want to be out of service for an hour and half driving to the next county.

This is all assuming that you are not experiencing a true emergency. If you have sudden trouble breathing, or collapse, or have some other true, acute problem, then we are here for you.

15 December 2007

Bernard Zee has some awesome photos of the Blue Angels and more from SF's Fleet Week. Check out the high-speed sneak pass below -- the plane looks to be about 15 feet off the deck at 700 mph! Great flying, and great photography!

And check out the supersonic shockwaves causing optical distortion (better seen in the full-size image):From Airliners.net, an image of a 757 on approach with a lovely example of compression condensation off the flaps as well as wingtip vortices.And a nice beauty shot of a restored Beech Staggerwing, rebuilt from the frame up by the masters over at Pemberton & Sons in Spokane.Now get off the internet and go enjoy your weekend.

14 December 2007

I walked in to work for the morning shift a few weeks ago, staffing the "flex pod" of the ER -- an area of acute care, monitored beds which we open from 10AM-2AM. There was, predictably, a row of patients lined up waiting for me to see them, as the charge nurses love to stack the pod before the doc even arrives. There were, however, no nurses in sight. I signed on to the computer and skimmed through the complaints to see what my morning was going to look like: two chest pains, one shortness of breath, one generalized weakness, one abdominal pain/vomiting. Not too bad; par for the course.

The tech wandered over and dropped the above ECG on my desk, from the generalized weakness patient. Any medical students out there, or readers who remember my previous post, The Wrong Juice, might recognize the wide QRS complexes and peaked T-waves as being highly suspicious for Hyperkalemia, a dangerous elevation of the potassium level in the blood. Elevated potassium will also cause muscle weakness, and is well-known for causing sudden death. It's one of those medical emergencies that make ER docs smile, because it's real, it's dangerous, it's dramatic, and we can fix it. A quick review of this patient's chart showed no history of kidney disease or any reason for elevated potassium, but the ECG changes were decidedly new. So I leaped into action.

Or I would have, except that there were STILL no nurses anywhere to be found. Where the hell were they? I went and briefly said "hi" to the patient and did a cursory history, noted that he did not have so much as an IV line started, and then went looking for a nurse. Finally, one strolled in, carrying her cup of coffee and chatting with the unit clerk; apparently they had gone off to the coffee stand while waiting for me to arrive.

I pounced on her: "The guy in bed D has a really abnormal ECG and I think he might be hyperkalemic, so let's get a line in him and an iStat ASAP."

She looked at me with a blank expression, "Oh, OK. I'll get right on it." And she turned back to the clerk to finish their conversation. Stunned at her inactivity, I hesitated a moment before interrupting.

"No, I need you to do this NOW. This guy may well code on us if we don't get cracking!"

Visibly annoyed at my rudeness, she put down her coffee, rolled her eyes to the clerk, and shuffled off to the IV cart. Satisfied that she was on it, I wen on to see the waiting chest pain patient, with the instruction that she was to bring me the iStat as soon as it was back. Ten minutes later, I was finishing up with the chest painer who sounded like he might have unstable angina, and I came back to the nursing station to see the nurse sitting there drinking her coffee and continuing to gossip! "Where's the result on D?" I asked.

Nonchalantly, she replied "Oh, he was a hard stick and I couldn't get it, so I asked Betty to try."

I glanced in the room: there was nobody there. "So where the hell is Betty?"

"I don't know. She said she would be right over."

"Go get her right now and get an line in him!" With a sense of growing anxiety I went in to see the next chest painer, who had a history of several past heart attacks. I rushed through the H&P and came out to see the first nurse and Betty sitting there chatting amiably. "Well, do we have a line?"

"Oh, yes," Betty responded in a voice that made clear that she thought I was silly for being so worked up over such a little thing. She had been around for 30 years and thought all the doctors were like children, to be placated, but of no real importance. "But," she went on, "I got the line but it didn't draw, so I called for the lab to come draw the blood." She turned back to her conversation.

"Aaarrrgh! Get me a needle and I'll draw the damn blood myself!"

"Oh, don't be silly. Lab'll be here any minute." As I rooted through the drawer looking for a needle, I noticed the pulse ox on my next patient, who was short of breath, was 88%. Crap. Gotta prioritize. So I went to see that patient, hoping against hope that there might be SOMEBODY on shift today who would do their job. When I came out, the nurses had not moved, but they did confirm that the blood had been drawn.

"Where are the results?"

"I dunno. Maybe in the lab?"

Ultimately I had to personally walk down to the lab (not far, fortunately) to determine that yes, indeed, the patient's potassium was >9 (normal 3.5-4.5). On my way back I stopped by the charge nurse to discuss with her the fact that I had a very sick patient and the staff did not seem to share my sense of urgency. She promised to kick-start them, and fortunately, I had the patient treated and off to stat dialysis soon enough.

But the rest of the day was no different. Note that during this whole time the nurses weren't exactly jumping on the other patients, either. Getting anything done was like pulling teeth. I hate to rag on nurses, since without them I get nothing done, and many a good nurse has saved my ass. But good lord it's infuriating when you are stuck with the "B" team.

I walked in to work for the morning shift a few weeks ago, staffing the "flex pod" of the ER -- an area of acute care, monitored beds which we open from 10AM-2AM. There was, predictably, a row of patients lined up waiting for me to see them, as the charge nurses love to stack the pod before the doc even arrives. There were, however, no nurses in sight. I signed on to the computer and skimmed through the complaints to see what my morning was going to look like: two chest pains, one shortness of breath, one generalized weakness, one abdominal pain/vomiting. Not too bad; par for the course.

The tech wandered over and dropped the above ECG on my desk, from the generalized weakness patient. Any medical students out there, or readers who remember my previous post, The Wrong Juice, might recognize the wide QRS complexes and peaked T-waves as being highly suspicious for Hyperkalemia, a dangerous elevation of the potassium level in the blood. Elevated potassium will also cause muscle weakness, and is well-known for causing sudden death. It's one of those medical emergencies that make ER docs smile, because it's real, it's dangerous, it's dramatic, and we can fix it. A quick review of this patient's chart showed no history of kidney disease or any reason for elevated potassium, but the ECG changes were decidedly new. So I leaped into action.

Or I would have, except that there were STILL no nurses anywhere to be found. Where the hell were they? I went and briefly said "hi" to the patient and did a cursory history, noted that he did not have so much as an IV line started, and then went looking for a nurse. Finally, one strolled in, carrying her cup of coffee and chatting with the unit clerk; apparently they had gone off to the coffee stand while waiting for me to arrive.

I pounced on her: "The guy in bed D has a really abnormal ECG and I think he might be hyperkalemic, so let's get a line in him and an iStat ASAP."

She looked at me with a blank expression, "Oh, OK. I'll get right on it." And she turned back to the clerk to finish their conversation.

"No, I need you to do this NOW. This guy may well code on us if we don't get cracking!"

Visibly annoyed at my rudeness, she put down her coffee, rolled her eyes to the clerk, and shuffled off to the IV cart. Satisfied that she was on it, I wen on to see the waiting chest pain patient, with the instruction that she was to bring me the iStat as soon as it was back. Ten minutes later, I was finishing up with the chest painer who sounded like he might have unstable angina, and I came back to the nursing station to see the nurse sitting there drinking her coffee and continuing to gossip! "Where's the result on D?" I asked.

Nonchalantly, she replied "Oh, he was a hard stick and I couldn't get it, so I asked Betty to try."

I glanced in the room: there was nobody there. "So where the hell is Betty?"

"I don't know. She said she would be right over."

"Go get her right now and get an line in him!" With a sense of growing anxiety I went in to see the next chest painer, who had a history of several past heart attacks. I rushed through the H&P and came out to see the first nurse and Betty sitting there chatting amiably. "Well, do we have a line?"

"Oh, yes," Betty responded in a voice that made clear that she thought I was silly for being so worked up over such a little thing. She had been around for 30 years and thought all the doctors were like children, to be placated, but of no real importance. "But," she went on, "I got the line but it didn't draw, so I called for the lab to come draw the blood." She turned back to her conversation.

"Aaarrrgh! Get me a needle and I'll draw the damn blood myself!"

"Oh, don't be silly. Lab'll be here any minute." As I rooted through the drawer looking for a needle, I noticed the pulse ox on my next patient, who was short of breath, was 88%. Crap. Gotta prioritize. So I went to see that patient, hoping against hope that there might be SOMEBODY on shift today who would do their job. When I came out, the nurses had not moved, but they did confirm that the blood had been drawn.

"Where are the results?"

"I dunno. Maybe in the lab?"

Ultimately I had to personally walk down to the lab (not far, fortunately) to determine that yes, indeed, the patient's potassium was >9 (normal 3.5-4.5). On my way back I stopped by the charge nurse to discuss with her the fact that I had a very sick patient and the staff did not seem to share my sense of urgency. She promised to kick-start them, and fortunately, I had the patient treated and off to stat dialysis soon enough.

But the rest of the day was no different. Note that during this whole time the nurses weren't exactly jumping on the other patients, either. Getting anything done was like pulling teeth. I hate to rag on nurses, since without them I get nothing done, and many a good nurse has saved my ass. But good lord it's infuriating when you are stuck with the "B" team.

[Addendum: as Gruntdoc pointed out, criticizing nurses can be dangerous to your health, so note it's just the "B Team" that makes me crazy. And there are docs on the "B Team," too.]

13 December 2007

Probably the most frustrating thing about the malpractice crisis is the "crap shoot" element that is introduced by carefully selected juries composed of uneducated laypersons making judgments on complex and controversial technical matters.

A lot of doctors on the web get very emotional about suits, especially ones in which they are named. And I think we all hate practicing in the environment of "what if it happens to me?" It's scary; every single day I wonder what will happen if the patient I am seeing right now will be the one to go home and die unexpectedly from some unforseeable disease or complication. The grieving family will take the stand and testify what a loving father/mother the patient was, a hired gun expert will testify that Dr Shadowfax was clearly negligent, and the jury will feel sorry for them and award the survivors a gajillion dollars.

So I practice defensively, admit more people than really need it, order a lot of tests just in case, and, most importantly, chart incredibly defensively, especially with anyone I am sending home.

It sucks, and it sucks all the more because I don't have any confidence that when I do get sued (it will happen, odds are) there is no reason for me to assume that the quality of the care I gave will have any bearing on the ultimate outcome.

What I want, both as a practicing physician and as the manager of a large medical group, is for a system that accurately relates "bad care" and financial liability. It's not personal, to me. Our group takes care of over 150,000 patients annually, and in a high-acuity environment like ours, staffed by fallible human beings, mistakes are going to happen. So compensating injured patients is and ought to be just a cost of doing business.

But the problem is that it's not predictable, or rather that it is predictable for the wrong reasons. A sympathetic plaintiff is a potent threat, and I can recall several cases which we settled despite excellent care, because the risk of a huge judgment was too high. On the other hand, I have seen a number of cases where the care was, let's say "debatable," but our attorneys play the game well and the lawsuit went away. Certainly we win more than we lose, so if some contend the system is rigged in our favor I wouldn't necessarily disagree, and we can tell a case that is a potential loser, so there is some predictability.

But it's still broken. We're compensating the wrong patients, and not compensating those that should be.

If I were to redesign the med mal system, I would include the following elements:

1. Patient compensation fund.It would more or less replace professional liability insurance, and would require actuaries to determine to what degree it needed to be funded. Funding could come from a variety of sources, including "premium payments" by healthcare providers or by surcharges on healthcare services or even by taxes, if that was thought to be good policy. Patients who had been determined to have been injured through medical error or negligence could be compensated according to a standardized schedule.

2. Administrative health courtsJudges with training in healthcare law/liability would preside and juries would consist of a mix of doctors and consumer advocates with special training. Patients who thought they had been injured could apply to the courts, discovery & testimony would be gathered as they are today, and the jury would issue a finding of fact. Verdicts might be: no injury; injury due to error; injury due to negligence; injury due to gross negligence. The courts would have the authority and duty to refer cases of negligence to the license boards for review. A summary of the findings of every case would be made public (with details redacted for privacy) to allow the medical industry to learn from the cumulative experience of the courts. And -- critically -- cases which had been previously decided could be used as precedent to guide future care as well as future cases.

10 December 2007

Working a slow night shift, and my brain is poorly functional due to sleep deprivation, and I don't trust myself to actually write a real, original post. So I'll throw out the links to the posts I found most interesting tonight:

Joe Paduda explains in the journal of the American Academy of Actuaries why he thinks health care reform may actually be inevitable this go-round. (warning: PDF)

I had drafted a post on why mandates of some sort are essential to making a national health plan work. Maggie Mahar does a much better job, so I deleted mine. Go read hers. Spoiler: it's all about the risk pooling.

MedinformaticsMD joins in the outcry about Sec Leavitt's "Don Corleone" offer that physicians can't refuse: get an EMR or miss out on those lavish medicare reimbursements!

DrRich at Covert Rationing writes about the government's regulatory speed trap set for physicians in the vague and ill-defined documentation guidelines.

06 December 2007

Reporter: Dana, on Tuesday at his press conference, when the president was asked about when he learned about Iran's nuclear program being halted, was he being completely candid?

Perino: Yes, he was ... If you look at the rest of that sentence, what the president is -- the president was clearly told that there was new information that was coming in, but he wasn't told the details of it. And the president was also told that the intelligence community was going to need to go back and check out to find out if it's true. What I said is that [Director of National Intelligence Mike] McConnell told the president if the new information turns out to be true, what we thought we knew for sure is right: Iran does, in fact, have a covert nuclear weapons program, but it may be suspended. He said that there were many streams of information that were coming in. They could potentially be in conflict. They didn't have a lot of confidence in the information yet.

Reporter: But the president said, "He didn't tell me what the information was." But you're now saying he was told that Iran may have halted its nuclear weapons program and also that there may be a new assessment, right?

Perino: Right, but he doesn't -- he didn't get any of the details of what -- what the information was, in terms of what the actual raw intelligence was.

Reporter: But he didn't say "details." He just said, "He didn't tell me what the ... "

Perino: OK, look. I can see where you could say that the president could have been more precise in that language. But the president was being truthful ...

In the back of the new White House press briefing room is a small, nondescript booth in which a professional announcer records the proceedings in detail for the National Archives. C&J has obtained a transcript of his commentary from Tuesday's press conference with the president:

"President Bush is practically standing still now. He's dropped the news that he didn’t know until last week that Iran had suspended its nuclear weapons program; and, uh, he's being questioned by an NBC reporter. It's starting to get tense; it's---the tension had, uh slacked up a little bit. The president is spinning, uh, just enough to keep the truth from... He's burst into flames! His pants have burst into flames, and he's falling, he's crashing! Watch it! Watch it! Get out of the way! Get out of the way! It's fire---and he's crashing! He's crashing terrible! Oh, my! Get out of the way, please! His slacks are burning and bursting into flames; and the---and it's melting Helen Thomas's shoes. And all the folks agree that this is terrible; this is the worst of the worst catastrophes in the world. Its flames... Crashing, oh! Four- or five-hundred words into the press conference and it---it's a terrific crash, ladies and gentlemen. It's smoke, and it's flames now; Oh, the humanity! And all the reporters screaming around here. I told you; it---I can't even talk to people... Ah! It's---it---it's a---ah! I...I can't talk, ladies and gentlemen. Honest: his credibility is just laying there, mass of smoking wreckage. His poll numbers are plunging into the teens. Oh! And everybody can hardly breathe and talk and Lady, I...I...I'm sorry. Honest: I...I can hardly breathe. I...I'm going to step outside, where I cannot see it. Listen, folks; I...I'm gonna have to stop for a minute because... I've lost my voice. This is the worst thing I've ever witnessed..."

Fortunately Condi Rice stopped by and was able to snuff out the fire by staring at it.

One of the things in the ER is that we do the same thing over and over, and what is routine to us is very abnormal to patients. Certain things predictably draw comments from patients, and as a result, there are some conversations I seem to have over and over again. One predictable one goes like this:

The setting: seeing a normal, healthy female patient between the age of 20-40, for an acute complaint such as chest pain. As part of the physical exam, I need to look at the lower legs, shins and calves, to evaluate for edema or signs of a blood clot. I lift the sheet and if necessary pull up the hem of the pants legs to expose the skin.

Patient: Oh my God, I'm so embarassed. I didn't shave today! Me: (reassuring tone) Don't worry about it, I'm just checking for fluid retention.Patient: (increasingly mortified) I just never thought you would need to go there...Me: It's OK, I'm not easily offended.Patient: Oh, no, I'm so embarassed.Me: (firmly) Listen, honey, this is the ER. 'Round here, if you've bathed at all in the last week you're ahead of the crowd. You really don't need to be embarassed.

It never fails to elicit a laugh, and to defuse the tension. But it's also true -- it seems that the hygenic standard for ER patients is ... somewhat lower than in my social circles. Sadly, I also have basically the same conversation doing pelvic exams.

However, it seems to me that this marks the final and complete step in the discrediting of the Bush administration.

For sure, it fatally undercuts their well-publicized drive for increased international sanctions on Iran, let alone military action. Which is a policy setback for Bush, but not much more.

However, the damage this does to Bush's believability is more severe and probably more lasting. Granted, not that he retained any sort of reputation for integrity after the last six years of incessant lies, but this is a rare moment, to be savored, in which his bald mendacity is exposed on the international stage, beyond any sort of plausible deniability or spin.

Of course, he has fallen back on the standard conservative-caught-in-a-lie classic excuse "I have no clue what the fuck is going on," most recently covered by Al Gonzales, to the effect that he vaguely remembered someone wandered through his office in August, possibly his Director of National Intelligence, possibly someone on a tour, and maybe mentioned something new about the Most Dangerous Nation on the Planet. But he didn't get specific and Bush didn't ask. Meanwhile, senior staffers in the White House must have been aware of the conclusions of thie NIE for the better part of a year, but never bothered to tell their boss, Bush never followed up with the DNI, and Bush continued to warn of "World War III" with Iran, while down the memory hole the NIE went.

Well, until the DNI decided, on his own initiative, to declassify the NIE "since the new estimate was at odds with the 2005 assessment — and thus at odds with public statements by top officials about Iran — 'we felt it was important to release this information to ensure that an accurate presentation is available.'” Or, in other words, "since we saw that Bush was continuing to ignore countervailing intelligence reports just like he did in 2003 with Iraq and we wanted to call bullshit on him." Maybe the intel community didn't want to be the fall guy (again) when we invaded Iran and found no WMD nukes.

So once again we are forced to decide which is more credible: that senior leaders in the Republican administration, in this case including the President, are either shameless liars or criminally incompetent. Both are equally plausible, but given the history of cherry-picking intel to create a pretext for an ideologically-driven war of choice, I'd have to say that in this case it was deliberate effort to deceive.

It really is satisfying to see him get caught red-handed in one of his lies, and in such a way that it shreds the remnants of his credibility in front of the entire world. This duck just got a little lamer.

04 December 2007

Blogging has now gone mainstream, as evidenced by bureaucrats like Secretary of Health and Human Services Mike Leavitt having blogs. (h/t to Roy at Health Care Renewal) I have to give him credit for stepping into the waters, addressing contentious issues, and allowing comments (though moderated). If only all of our government officials were so forthcoming....

Today's post involves the Sustainable Growth Rate, or SGR, which is the formula Congress established to determine how much physicians should get paid under Medicare. It's an unmitigated catastrophe. Sec Leavitt tries to explain the problem, and for such an arcane issue does a good job of succinctly doing so. Roy points out some of the problems with the SGR, but I also have some opinions. (shock!)

My $0.02:The SGR was adopted as a mechanism to cap the growth in expenditure for physician services under Medicare. (ironic note: no other service line is subject to this sort of cost controls; facility expenses can and have increased exponentially. I have never heard a good explanation why physician compensation was singled out for this sort of limitation.) In essence, the Medicare budget for doctors cannot increase faster than the GDP per capita.

BUT, the number of new retirees eligible for Medicare increases every year. And they live longer. And they have more chronic illnesses. And we have more things we can do to/for them. So the total amount of services provided increases faster than the GDP. Since the total amount of dollars available is fixed, and the number of services increases, the value of a given service, year to year, must go down. Sec Leavitt implies that this is somehow our fault, that doctors just do "too many procedures," but really it's a fact of demographics and the advance in medical science. Last year physician reimbursement was scheduled to go down 5% under the SGR, but we got a reprieve (in exchange for accepting the imposition of "Pay for Performance"). This year, we are scheduled for a 10% pay cut. Sec Leavitt has proposed another last-minute reprieve; however, in the linked post, he proposes that this freeze in payment cuts be conditioned on the requirement that physicians adopt electronic medical records and prescribing.

Now, I'm a gadget guy, and I love our ER's electronic tracking system. This sometimes makes me a pariah among physicians, but I can live with that. But it's expensive. And for some, it can be slow and cumbersome, and cut productivity. And the medical records generated by these products are not exactly user-friendly. So while I am a big proponent of the EMR in general, there's a legitimate question of whether they are ready for prime time, and where the money to cover the costs will come from.

Yet the Secretary of HHS wants to make them a national standard as the price for averting an undeserved pay cut for doctors, caused by the short-sightedness of Congressional policy-makers. Nice. Here's the comment I left on his blog (in case the moderating staff kills it):

Sec Leavitt,

I applaud that you recognize that the SGR is indeed a fatally flawed mechanism for determining physician compensation. However, given that you admit fully and candidly that the formula for determining the value of physician services has failed, you then propose that, in order to obtain the deserved compensation for the services rendered, physicians must jump through expensive hoops in adopting EMRs? It makes no sense, and it smells of extortion, to piggyback onerous, unproven, and unpopular new regulations onto fixing the SGR.

To deal with this crisis fairly, the two items should be de-linked. Congress screwed up with the SGR, so Congress should fix it. If as a matter of public policy, the administration thinks that EMRs or P4P or whatever "initiative of the week" should be made law, then let's have a open and unrestricted debate on the issue on its own merits.

But don't insult us by making fair payment for our services conditioned upon physicians rolling over and accepting irrelevant restrictions and regulations. It's an abuse of power, and not the way good policy is developed.

I rather doubt it will do any good, but it does feel good to tell those in power what you think.

29 November 2007

For 25 years Peter Garrett was the frontman of Midnight Oil, an Australian rock band known for its raucously loud music and protest songs about social and environmental issues. Then the bald 6ft 6in singer hung up his microphone, disbanded the group and exchanged his rock star clothes for the sombre suits of a politician. After a meteoric rise through the ranks of Australia's Labor party, he was yesterday named environment minister in the newly elected government.

I remember seeing them live at Chicago's Poplar Creek in 1990 (yeah, I'm old) and again in 1993 at the World Music Theater. Damn they put on a fine show. Peter Garrett was one of the most amazing performers I have ever seen. The amount of energy he expended performing would have put James Brown to shame. Midnight Oil still figures prominently in my workout playlists. Weird to think of him as a "Minister" of anything, but I guess that's Oz, innit?

I have some experience with the RUC via the ACEP Reimbursement Committee, and while I have been pleased to some degree by the facility with which the representatives of Emergency Medicine have worked within that milieu, on the basis of self-interest, I can't stand the way in which it is structured and works.

Key points from the cited JAMA Article:

Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. [snip]

This problem will only be resolved with full recognition of its origins. Because physician decision making profoundly influences health care expenditures,11 the forces that affect these decisions must be addressed. Practice type and physician specialty are critical factors; both are associated with higher rates of test ordering and hospitalization. Generalists with long, continuous clinical relationships with patients tend to generate lower health care costs for their patients. Current reimbursement incentives substantially favor procedures and technical interventions and offer financial advantages for expensive care, thereby encouraging specialty services. [snip]

The American Medical Association (AMA) sponsors the resource-based relative value scale update committee (RUC) [...] The RUC has 30 members (the chair only votes in case of a tie) with 23 of its members appointed by "national medical specialty societies." Meetings are closed to outside observation except by invitation of the chair. Only 3 of the seats rotate on a 2-year basis. Other members have no term limits. Seventeen of the permanent seats on the RUC are assigned to a variety of AMA-recognized specialty societies including those that account for a very small portion of all professional Medicare billing, such as neurosurgery, plastic surgery, pathology, and otolaryngology. Proceedings are proprietary and therefore are not publicly available for review. Traditionally, more than 90% of the RUC's recommendations are accepted and enacted by CMS. [...] The resource-based relative value scale system "defies gravity" with the upward movement of nearly all codes. In 2006, based on RUC recommendations, CMS increased RVUs for 227 services and decreased them for 26. [snip]

By creating and maintaining incentives for more and more specialty care and by failing to accurately and continuously assess the practice expense RVUs, the decisions of CMS have fueled health care inflation. Doing so has affected the competitiveness of US corporations in the global market by contributing to years of double-digit health care inflation that have consistently increased the costs of manufacturing and business in the United States over the last decades.

The continued and sustained incentives for medical graduates to choose higher-paying specialty careers and for those physicians in specialty careers to increase income through highly compensated professional activities have been associated with the dwindling of the generalist workforce. The lack of incentives for medical graduates to choose generalist careers in internal medicine, family medicine, and pediatrics has had a profound effect on the workforce mix and, ultimately, US health care expenditures.

Residents are choosing not to enter the generalist fields. For instance, among first-year internal medicine residents, less than 20% have interest in pursuing careers in general internal medicine. Past trends indicate that only slightly more than half of these residents continue this commitment to general internal medicine to the completion of residency. If this continues, as few as 10% of those training in internal medicine will to work as general internists.

There's more, and I encourage those of you with access to read the full article.

I have blogged in the past about the perversity of the reimbursement system and the way it inappropriately rewards procedural services over cognitive services. It makes me crazy that I get paid more for stitching up a minor facial laceration than I do for deciding whether your chest pain is an impending heart attack. (CPT 12052 (laceration) = 4.37 RVU; 99285 (E/M) = 4.01 RVU) Severalotherexcellent health care bloggers have opined, some extensively, on the same topic.

I don't take much issue, as does rcentor, in the relative secrecy of the RUC. My experience is that horse-trading like this is something best done behind closed doors. We don't expect GM and the UAW to open their negotiations to the public, and in the same vein, I would not expect the inter-specialty wrangling to be aired publicly. What I do take issue with is the composition of the committee, which I see as the key driver of weighting towards specialty services and procedures.

As noted above, the RUC is to a very large degree dominated by specialists. There is, I am reliably told, an informal alliance between the procedure-based specialists, which would include surgeons (General, Thoracic, Ortho, Spine, Neuro, Urology, Plastics, Optho, ENT, OB/GYN) and "medical specialists" who derive much of their revenue from procedures (cardiology, radiology, anesthesiology, dermatology). Together these specialties control about 60% of the seats allocated to medical specialty societies. The primary care specialties, in contrast, control only 13% or three votes (Internal Med, Family Med, and Pediatrics). (Four, if you count Emergency Medicine, which is naturally aligned with primary care.)

Notable in the compostion of the RUC is the inclusion of most of the surgical sub-specialties, and almost complete exclusion of the medical ones. Oncology, Neurology, and Pulmonary are there, and not a single other medical specialty is represented. Neither is there any proportionality to the representation. The 6,000-member American Society of Plastic Surgeons has the same amount of influence as the 124,000-member American College of Physicians.

In a self-serving game of "you scratch my back," the proceduralists support the inflated work values of one another's new procedures, and as the values float further and further higher over time, and as the number of procedures grows, the value of office-based or cognitive services diminishes in relation. And as there is only one pie to split up, the slice of the pie that goes to primary care shrinks and shrinks. Now we are at the crisis point. Primary care as currently practiced is no longer economically sustainable, and medical school graduates see this and make a rational choice to pursue more remunerative careers.

Sadly, I don't see this changing unless there is a major revision to how the RVU system is determined, and I fear that the established players are well-enough entrenched that they will be able to derail any meaningful reform. This is an arcane enough issue that it's hard to explain to the policy-makers, and those whose income would be threatened by changes will predictably object and confuse the issue enough to obstruct the changes. But at least this topic is beginning to gain attention and traction at a national level, and maybe, just maybe, this might be a small first step on the road to reform.

'The oath leaves such voters with a touch choice to make: "lie," "stay home from the Feb. 12 elections and keep your options open," or "commit to an unknown Republican candidate nine months before the election."'

I work from time to time at a rural hospital up in the mountains. It's a pleasant change of pace from the high-intensity trauma center where I do the majority of my shifts. The acuity, volume, and patient population vary dramatically, as you might expect. The Big Hospital sees over 100,000 ED patients annually, whereas the rural shop sees less than 20,000.

One interesting consequence is that the nurses in the little hospital seem to know all the patients, either socially or from previous ED visits or both. Depending on the circumstances, it can be very helpful or very awkward (or both). One recent night, a woman came staggering into triage clutching at her lower back. The charge nurse groaned upon seeing her, and took me aside: "We know her from before. She's a big-time drug seeker, and has been caught on more than one occasion altering and forging prescriptions from this ER." She pulled out a binder where we keep "care plans" for patients with chronic pain and narcotic issues. The patient's history was laid out there in its sordid detail, and supported the Medical Director's recommendation that this individual not be prescribed narcotics. "Just kick her out of here, will you," the nurse suggested.

As helpful as this kind of advance knowledge is, I kind of hate it. I still have to go in and see the patient, and it's very hard not to be prejudiced about the encounter and give the patient a fair evaluation. Especially when the vast majority of time the prejudice would have been accurate. So I try to push the "drug-seeker" conclusion out of my mind until after spending some time with the patient. But it's not easy.

This encounter, however, did not seem likely to diverge from my preconceived expectations. She informed me that this was her standard back pain for which she was on a staggering dose of narcotics (OxyContin, 80 mg TID plus oral Dilaudid!) but the pain had just become intolerable. It was with a sense of despair that I went through the formulaic questions necessary to differentiate chronic back pain from an acute emergency, and her answers were bland and unrevealing. I noticed, though, that she was sort of writhing on the bed, and when I asked her directly, she said that, yes, in fact, the pain was coming in waves. Hmmmm. Might there be something more than myofascial back pain?

So I got a simple test: a urinalysis. It showed a microscopic amount of blood in her urine. The nurses rolled their eyes at me when I ordered a CT scan of her abdomen, but to my mild surprise and infinite satisfaction, the scan showed a large obstructing kidney stone!

It just goes to reinforce the old adage that even drug-seekers get sick, too. But then I found myself with a conundrum: how on earth was I going to control her pain. When you are on high doses of pain medicines, they lose their potency, and I estimated that I could use all the morphine in the hospital without making a dent in her pain. Worse, she had deteriorated somewhat in the time it took to get the scan, and when I saw her again, she was pale and covered in a sheen of sweat.

Predictably, she was "allergic" to Toradol, as many drug-seekers claim to be (it doesn't provide the euphoria that narcotics do) but when I questioned her carefully she said it just "upset her stomach" and "doesn't work for me." So I explained that I thought narcotics would not help her pain, but I thought Toradol might, and she agreed to give it a try.

Forty minutes later I checked on her again and she was resting comfortably. With gratitude, she said, "I can't believe how well that stuff worked! I never would have thought it." A little while later, she went home, feeling "100% better," and I faxed some prescriptions over to the pharmacy for her. By god, it is satisfying when things works like they are supposed to, and in this case, it perfectly split the Gordian knot of pain management in the opiate-addicted patient.

20 November 2007

The triage note was not encouraging. "Migraine. History of same x 10 years. Workups included (-) CT, MRI scans. Has had daily migraine x four weeks. Pain not relieved with Imitrex today." A quick glance at the previous visit list revealed a number of ER evaluations for headaches, though not too many. He usually got dilaudid for his headaches.

"Migraines" suck the life force out of me. They are rarely in fact, migraines, but simply tension headaches versus undifferentiated headaches. The frequent headache patients usually require large doses of narcotics to "fix" and have strong affective components to them (I've cured a few migraines with ativan, an anti-anxiety medication which has no pain-relieving properties). There are many frequent headache patients who are simply seeking drugs. I try to avoid narcotic meds when possible, because of abuse potential, because they often provide only short-term relief, and because they can induce rebound headaches.

This guy seemed nice enough. He didn't present the dramatic emotional display that many faux-headaches show, and he was a somewhat unusual headache patient in that he was a) male and b) gainfully employed. I offered him the same initial treatment I do any other benign headache: toradol, a non-narcotic pain reliever, and some vistaril, an anti-nausea medicine. I braced myself for the inevitable objection: "That doesn't work for me" or "Oh, I just remembered, I'm allergic to toradol." But it didn't come. He had never heard of it, and apparently trusted me enough to give it a go. So I ordered the meds and went off to see the next patient in the queue.

Forty-five minutes later I dropped by his room to see how he was feeling. He was sitting up, with the lights on, rubbing the back of his neck with a look of amazement on his face. "Doc, I don't know what it was that you just gave me, but it was magic! I feel better than I have in weeks!" His wife wondered why no ER doc had ever given it to him before.

He went home happy and feeling well, and I went to see the next patient with a smile on my face. It's so nice when things work like they are supposed to...

Presumably, you felt just as much outrage over Bill Clinton's many recess appointments. Or are they only "unconsitutional" when a Republican makes them?

Fair question, and deserving a fair response:

There is a difference between the context, degree, and manner in which the two presidents used this authority. Clinton issued 140 recess appointments; Bush is on track for somewhere around 220. Clinton issued almost all recess appointments in the six years in which Congress was controlled by the opposing party; Bush has used this authority to a great degree when his own party controlled the Senate. Clinton, to all evidence, generally pursued consensus appointees; Bush is notorious for appointing polarizing candidates and has never sought input or consensus from the opposition party.

During the last six years of the Clinton Presidency, the republicans in control of congress obstructed consideration of Clinton's appointees, including in many cases refusing to even schedule hearings on them and/or refusing to bring them up for committee votes. During the Bush years, the Senate has been incredibly compliant in confirming Bush's nominees, even (amazingly) when it was controlled by democrats. Good data is hard to come by, but in a brief Google search, it appears that the Senate has confirmed ~95% of Bush's judicial appointees, whereas under Clinton the number was closer to 70%. (I'd appreciate a correction if anyone has better numbers.) Many of the cases in which Bush used the recess appointments were for applicants who had already been rejected by the Senate or in some cases, who he did not even submit to the Senate, knowing that they would never get confirmed.

It is difficult to define an objective distinction between valid use of this authority and abuse of this authority. Having said that, the conclusion I draw from the above is this:

Clinton used RAs to resolve the political stalemate created by a hostile congress which refused, in bad faith, to act on his appointees;Bush has used RAs to evade the constitutional requirement for Senate approval, or to over-ride the Senate's rejection of his candidates.

Clearly both Bush and Clinton used the power other than it was intended by the Founders and I would support restrictions on its use in the future.

Reid is simply not going to let the Senate go into recess, preventing the Little Emperor for doing an end-around and bypassing it. Small, but nice.

And more on the Death of Irony -- Salon's Glenn Greenwald points out this gem:

It's genuinely hard to believe that the writers of George Bush's speech last night to the Federalist Society weren't knowingly satirizing him. They actually had him say this:When the Founders drafted the Constitution, they had a clear understanding of tyranny. They also had a clear idea about how to prevent it from ever taking root in America. Their solution was to separate the government's powers into three co-equal branches: the executive, the legislature, and the judiciary. Each of these branches plays a vital role in our free society. Each serves as a check on the others. And to preserve our liberty, each must meet its responsibilities -- and resist the temptation to encroach on the powers the Constitution accords to others.Then they went even further and this came out:The President's oath of office commits him to do his best to "preserve, protect, and defend the Constitution of the United States." I take these words seriously. I believe these words mean what they say.To top it all off -- by which point they must have been cackling uncontrollably -- they had him say this:Others take a different view. . . . They forgot that our Constitution lives because we respect it enough to adhere to its words. (Applause.) Ours is the oldest written Constitution in the world. It is the foundation of America's experiment in self-government. And it will continue to live only so long as we continue to recognize its wisdom and division of authority.

15 November 2007

WASHINGTON (AP) -- Ahead of the holiday travel crunch, President Bush ordered steps Thursday to reduce air traffic congestion and long delays that have left passengers stranded.

President Bush, accompanied by acting FAA Administrator Robert Sturgell, outlined a plan to reduce air traffic congestion on Thursday.

The most significant change is that the Pentagon will open unused military airspace from Florida to Maine to create "a Thanksgiving express lane" for commercial airliners.

I don't know which is more depressing, that Bush thinks this is a plan that will actually ease congestion, or that the stenographers in our media are so ill-informed about aviation issues that they parrot this "express lane" catch phrase without actually analyzing whether it would actually, you know, work.

Thing is, unless this military airspace Bush is opening up happens to contain several dozen new commercial airports with terminals and runways and scheduled service, it's not going to do thing one to improve holiday travel. You see, the skies are what we pilots call "really big" and we just don't need much more maneuvering space to fit all the airplanes in them. In fact, every registered airplane in the US could be in the sky at one time and they would fit perfectly fine! As long as none of them ever had to take off or land, that is. Airports are somewhat smaller than the sky, and have limited capacity. The runways can handle only so many takeoffs and landings at once, there are not enough terminals for the scheduled commercial flights even absent delays, and the approach corridors to major airports can handle only so many planes at once.

To be fair (not my strong point) the rest of the article did list some more technical and useful measures the FAA is taking, and yes, in the event of inclement weather, a little more flexibility in re-routing might make delays less common. I particularly liked the idea of raising takeoff and landing fees at peak hours -- that makes sense and might encourage airlines to shift flights out of the peak times. None of these measures, however, fully addresses the fundamental problem -- too many airplanes trying to get onto too few runways at too few commercial airports at the same time.

Ten out of Ten writes about the factors that make a good shift, and I couldn't agree more. The right pen is essential to me -- I do so much writing that I am obsessive about having my special gel-ink pen which makes charting a pleasure. And having the "A" team of nurses will make or break your shifts as well. Go read it.

Over at Backstage Pass you can read about things that cause inefficiency in the ED. Since we are in the middle of building a new ED and trying to optimize the workflows of all the staff, this post really resonates with me.

14 November 2007

I don't generally do them, but I ran into a fun one over at EMS Haiku, and I've had a crappy day so I thought I would hijack it and indulge myself.

My Five Favorite aircraft:

Beech StaggerwingElegant and refined, aesthetically perfect. There's one that flies out of my home airport every few weeks and I love hearing the growl of its radial engine as it flies over my house... just beautiful.

Supermarine SpitfireEngland's premiere fighter-interceptor of WWII, with its distinctive elliptical wing, forever locked in mortal combat with its foe, the ME-109, in the Battle of Britain.

Lockheed ConstellationLovingly remembered as the "Connie," with the triple-tail design and gracefully arching fuselage lines. Last of the great piston- and propeller-driven airliners in the Golden Age of Aviation...

Adam A500As modern as the Connie is archaic, but sharing the same graceful design elements of flowing lines and a distinctive tail. The A500 was designed by Burt Rutan (legendary designer of the Voyager, Global Flyer, and Spaceship One). It features twin engines with centerline thrust, advanced avionics, seats six in luxury, cruises at 225 knots at 25,000 feet, and will set you back a cool $1.25 million. This plane is why I still play the Lotto.

Pitts SpecialShort, squat and incredibly maneuverable, the Pitts has come to represent aerobatics in the public mind. Since its introduction in the 1960s it has been eclipsed in competition by more agile spindly, ugly little things, but the Pitts remains a staple at airshows world-wide and is capable of any aerobatic maneuver that you can think of.

Tough to edit the list down to only five. I could list a dozen WWII planes alone as "favorites." (How could I leave the Corsair, or the Lightning off my list??!?) Decisions, decisions. I won't tag anyone with this, since I detest memes for the sake of memes. But if you like planes, feel free to run with it.

12 November 2007

Kevin links approvingly to a piece by the Happy Hospitalist which, by means of an unusual extended analogy involving pens, decries universal health as stifling to innovation. I think the Happy fellow may have a valid point in his follow-on post about the perverse facility reimbursement schemes used by medicare and the ways in which the rigging of the healthcare market drives competition in unsound ways; but I also think he draws an specious conclusion, though a common one among opponents, in asserting that universal healthcare will somehow stifle inflation.

Much of the innovation in healthcare is driven not by the private market, but by public financing, whether by the $28 Billion spent on the NIH each year, by researchers in other countries which do have universal health care, and by US taxpayers who fund Medicare and its coverage of innovative services (often at a premium cost). And the private market? While Cohn does not dispute the important role it plays, he also points out its intrinsic perversity:

[...] a lot of the alleged innovation we get from private industry just isn't all that innovative. Rather than concentrating on developing true blockbusters, for the last decade or so the pharmaceutical industry has poured the lion's share of its efforts into a parade of "me-too" drugs--close replicas of existing treatments that offer little in the way of new therapeutic advantages but generate enormous profits because they are patented and because companies have become exceedingly good at promoting their sales directly to consumers.

The most well-known example of this is Nexium, which AstraZeneca introduced several years ago as the successor to Prilosec, its wildly successful drug for treating acid reflux. AstraZeneca promoted Nexium heavily through advertising--you may remember the ads for the new "purple pill"--and, as a result, millions of patients went to their doctors asking for it. Trouble was, the evidence suggested that Nexium's results were not much better than Prilosec's--if, indeed, they were better at all. And, since Prilosec was going off patent, competition from generic-brand copies was about to make it a much cheaper alternative. (The fact that Prilosec's price was about to plummet, needless to say, is precisely why AstraZeneca was so eager to roll out a new, patented drug for which it could charge a great deal more money.)

The Nexium story highlights yet another problem with the private sector's approach to innovation. Because the financial incentives reward new treatments--the kind that can win patents--drug- and device-makers generally show little interest in treatments that involve existing products.

And one more recent media report highlights a reason to be leery of private, for-profit funding of healthcare: Health Net, a major insurer in California, avoided paying $35 million in benefits by canceling the policies of 1600 patients who became ill with cancer or other expensive illnesses. The policies were typically canceled based on a minor inaccuracy or omission on application paperwork, and "Cancellation Specialists" were paid bonuses of up to $20,000 for hitting targets for number of policies canceled.

I just don't understand the opponents of a national health system. I just don't understand.

11 November 2007

10 November 2007

I posted the other day about a satisfying evening in which I was fortunate enough to see a number of acute cases in a row. Frankly, none of them took a ton of diagnostic acumen -- bread and butter stuff for emergency medicine, really. It was, though, a nice day.

One thing that struck me about a particular case was how quickly it went bad -- very very bad.

It was a woman in her child-bearing years who suddenly collapsed (i.e. syncope) while watching a football game. She came in looking ill but with stable vital signs, complaining of severe abdominal pain which had come on at the moment she fainted. Her hematocrit on arrival was 27 -- indicating either chronic anemia or acute blood loss.

So I'm no dummy -- the first thing I thought of was a ruptured ectopic pregnancy. But her pregnancy test came back negative. I am an experienced ultrasonographer -- don't ask me to find the common bile duct, but I can see blood very reliably if it is there. So I dropped the ultrasound probe on her abdomen, and the results were perplexing. There was definitively no blood in Morrison's pouch, or in the spleno-renal recess, or in the pelvis. There was an odd hypoechoic stripe across the body of the liver. It looked like a blood vessel, but was too linear. In retrospect it was probably blood in the falciform fissure, or some anomalous similar structure. But again, there was clearly no free blood in the peritoneum at that time. But based on that odd finding, I called in the ultrasound tech for a formal study.

A very short time later (it was chaotic -- fifteen minutes?), she crashed. She became unresponsive and profoundly hypotensive, with a heart rate around 150 (from the 80's). Annoyingly, in her throes as she passed out, she managed to pull out both her IVs. A repeat hematocrit came back at 21 -- she was clearly losing blood rapidly; the ultrasound tech arrived while we were re-establishing IV access and beginning aggressive volume and blood resuscitation. He dropped the probe on the abdomen and I uttered a four-letter word, because the DRY abdomen I had seen shortly before was now FULL of fluid.

Fortunately, it was not difficult to persuade the on-call surgeon to come in and take this young lady directly to the operating room. The surgeon did a superb job to stanch the bleeding (from her ruptured Splenic Artery Aneurysm) and perform an emergency splenectomy. The patient survived (thanks in no small part to the Cell Saver) and did very well.

What was striking was how very quickly she went from "ill-but-stable" with an empty belly to "moribund-with-belly-full-of-blood." Amazing.

08 November 2007

Sad, but this really made my day: I just saw five patients, in a row, who all needed to be in the ER. Not for anxiety, or for alcohol and drug abuse, not for poorly controlled chronic illnesses, but for real, honest-to-goodness emergencies.

In no particular order there was:An acute hemiplegic strokeAcute AppendicitisA fall with a head injury and moderate grade concussionAn acute arterial thromboembolism to the hand(Most excitingly) a acute hemoperitoneum due to a ruptured artery in the abdomen (oddly enough, the splenic artery)

Wow. It's almost like I was working in a real Emergency Room or something.

Which is to say that NBC's The Office is the first major show to close production due to the writers' strike. Apparently the reason is that the cast and crew refused to cross the writers' picket lines. Star Steve Carell called in "sick" with the greatest work excuse ever:

Additionally, I've been told that Steve Carell informed NBC he is unable to report to work because he is suffering from “enlarged balls.” Not just enlarged, I'd say, but brass ones. The source on this one adds, "We wish him a happy, slow recovery."

Can't say we didn't see it coming, but it's official: Bush is now more unpopular than Nixon at his lowest -- the most awesome unpopular president evah!

Meanwhile, Bush reached an unwelcome record. By 64%-31%, Americans disapprove of the job he is doing. For the first time in the history of the Gallup Poll, 50% say they "strongly disapprove" of the president. Richard Nixon had reached the previous high, 48%, just before an impeachment inquiry was launched in 1974.

But he's not done yet! There is one more record left to break: lowest approval rating. He has only another four points to go (in Gallup) before he will be the undisputed champion. I have faith in him.

27 October 2007

One of the things I love about this blog, is that a lot of my readers, like me, work odd hours. I enjoy seeing the timestamps on the emails and comments; a surprising number of them originate between 0100 and 0400 hours. I guess a lot of ER types get bored and read blogs on the night shift.

One of the things I don't like about my job is that I have to work nights. Don't get me wrong -- I worked nights exclusively for a few years before I had kids, by choice. I like the pace of night shifts, I like the occasional down time, I like the camaraderie that the night staffs always seem to enjoy, and I even learned to like the traditional post-night shift team meal of pancakes and beer. That was when I was working all nights. Now I just work the same fraction of nights as the other docs in our group, a handful per month, and I find them much harder. It's easier to flip the sleep/wake cycle when you're going to work five nights in a row. One or two stand-alone night shifts are a lot more disruptive to my biological rhythms. And it's well known that as you get older, your ability to handle the sleep deprivation gets less and less.

This is why I was interested to hear a lot of buzz recently about a medication called Provigil (Modafinil). It apparently is FDA approved for the treatment of "Shift Work Sleep Disorder," a disease which I am pretty sure did not exist before the good folks at Cephalon decided to market the drug to shift workers. It is basically a stimulant which is more effective than caffeine, milder than amphetamines, and with a lower side effect and dependence profile than other stimulants. I attended a few lectures at ACEP's Scientific Assembly which addressed this issue -- both from a quality of life perspective as well as a physician performance and patient safety perspective -- and I was surprised to hear an almost evangelistic level of enthusiasm for this drug from the speakers. I have personally known a few ER docs who have tried it and they also rave about its virtues. They say that you are just blissfully awake for that awful first night up, without the jitters from caffeine, without feeling edgy or off-kilter, and you are able to sleep the next day -- there's no hangover.

It's got me wondering. I have never self-medicated (other than with coffee or booze or the occasional antibiotic), and I am not about to start. If nothing else, it is a schedule IV med. (It's also on the FAA's list of forbidden drugs for a pilot to take, which is ironic since apparently the Air Force uses it to improve pilot alertness on long missions.) But I am tempted to take the commercial's advice and "ask my doctor about a free trial..."

I'd be interested to hear any experiences any of my readers might have with this medicine -- especially any of the under-reported down sides. It sounds too good to be true, which means it probably is.

EPILOGUE

I wrote this post in a slow moment of an overnight shift. I hadn't thought I was particularly tired, but once I was on my way home a wave of fatigue broke over me and really took me by surprise. I almost fell asleep at the wheel and drove off the road several times. Scary -- thank God for rumble strips on shoulders! Fatigue impairs your judgment; I should have gotten the hell off the road but I was afflicted with a severe case of get-there-itis. I managed to focus myself after the second or third time it happened and made it home without incident.

I don't think it makes a compelling point for or against Provigil, but it's a disturbing irony to occur three hours after writing a post on sleep issues...

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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